The American College of Physicians (ACP) sets the framework for a team-based model of health care in a new policy paper published today in the peer-reviewed medical journal, Annals of Internal Medicine. ACP offers more than a dozen principles to encourage and enable clinicians to work together effectively in dynamic clinical care teams. The policy paper, Principles Supporting Dynamic Clinical Care Teams, outlines a process for creating more nimble, adaptable partnerships that encourage teamwork, collaboration, and smooth transitions of responsibility to ensure the needs of patients are met at each step of the way.

"We hope to encourage positive dialogue among all health care professions to advance team-based and collaborative models that are organized for the benefit and best interests of patients," said Molly Cooke, MD, FACP, president of ACP. "In addition, regulatory and payment polices must be aligned with, and support team-based care models rather than creating barriers."

While reaffirming its support of the Joint Principles of the Patient-Centered Medical Home in the paper, ACP said it recognizes that the current model of health care delivery will need to change to meet the coming demand of patients.

"Internists are particularly well-qualified to care for adults with complex illnesses and diagnostic challenges," Dr. Cooke said. "Depending on their specific clinical needs and circumstances, however, patients might appropriately be seen by other members of the clinical care team with physicians being available for referral or consultation as needed."

Highly-functioning teams typically assign responsibility and authority for distinct organizational domains to the person or persons most appropriate for the tasks required, the paper says. Clinical care teams will vary in their composition depending on the medical specialty (e.g., internal medicine or cardiology), the clinical setting (inpatient, outpatient, small practice, large institution) and will vary in their function depending on leadership, institutional policies, available team members, even individual talents and characteristics of specific team members. Optimal effectiveness of clinical care teams requires a culture of trust, shared goals, effective communication, and mutual respect for the distinctive skills, contributions, and roles of each team member.

"These principles offer a framework for an evolving, updated approach to health care delivery, providing policy guidance that can be useful to clinical teams themselves in organizing their care processes and clinician responsibilities consistent with professionalism," Dr. Cooke pointed out.

The paper's principles cover four categories—professionalism, licensure, reimbursement, and research and include:

Assignment of specific clinical and coordination responsibilities for a patient's care within a collaborative and multi-disciplinary clinical care team should be based on what is in the best interest of that patient, matching the patient with the member(s) of the team most qualified and available at that time to personally deliver particular aspects of care and maintain overall responsibility to ensure that the clinical needs and preferences of the patient are met.

ACP reaffirms the importance of patients having access to a personal physician, trained in the care of the "whole person," who has leadership responsibilities for a team of health professionals, consistent with the PCMH joint principles.

ACP also recognizes that dynamic teams must have the flexibility "to determine the roles and responsibilities expected of them based on shared goals and needs of the patient" as noted by the authors of a 2012 Institute of Medicine discussion paper on Core Principles & Values of Effective Team-Based Health Care.

Accordingly, while physicians have extensive education, skills and training that make them uniquely qualified to exercise advanced clinical responsibilities within teams, well-functioning teams will assign responsibilities to advanced practice registered nurses and other registered nurses, physician assistants, clinical pharmacists, and other health care professionals for specific dimensions of care commensurate with their training and skills to most effectively serve the needs of the patient.

ACP also acknowledges that in many communities, there are severe and growing shortages of physicians (particularly shortages of internal medicine physician specialists and other physician specialties trained in primary and comprehensive care), which is a barrier to achieving the vision of every patient being able to have "an ongoing relationship with a personal physician trained to provide first contact, continuous and comprehensive care," as called for by the Joint Principles of the Patient-Centered Medical Home. A cooperative approach including physicians, advanced practice registered nurses and other registered nurses, physician assistants, clinical pharmacists, and other health care professionals in collaborative team models will be needed to address such shortages.

A unique strength of multidisciplinary teams is that clinicians from different disciplines and specialties bring distinct training, skills, knowledge base, competencies, and patient care experiences to the team, which can then respond to the needs of each patient and the population it collectively serves in a patient- and family-centered manner.

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